Emphasizing the biopsychosocial dimension in post-traumatic orthopedic recovery

Abstract

Chronic pain and disability following acute orthopedic trauma are not only physical concerns but also deeply intertwined with psychological well-being. The recent retrospective cohort study by Yang et al, published, provides compelling evidence of significant associations between depression, anxiety, and postoperative recovery. These findings align with an expanding body of literature that confirms the need for orthopedic rehabilitation to adopt a biopsychosocial perspective. This letter contextualizes Yang et al’s study within current evidence, highlighting the roles of sleep disturbance, catastrophizing, stress, neurobiological mechanisms, and coping strategies in shaping recovery. It further emphasizes the importance of integrating nursing-led and multidisciplinary interventions to address both physical and psychological domains, ultimately promoting holistic recovery.

Key Words: Orthopedic trauma; Chronic pain; Disability; Depression; Anxiety; Biopsychosocial model; Coping strategies

Core Tip: Chronic pain and disability after orthopedic trauma are not only biomedical outcomes but are also closely tied to psychological health. The study by Yang et al emphasizes the importance of depression and anxiety in recovery. Drawing on recent evidence, we argue that sleep, fatigue, coping strategies, and social context must also be integrated into care. A biopsychosocial, multidisciplinary approach - where psychological screening and nursing-led interventions are routine - can promote holistic recovery and improve long-term outcomes.

TO THE EDITOR

The recent retrospective cohort study by Yang et al[1], published in the World Journal of Psychiatry, provides essential evidence linking chronic pain and disability after acute orthopedic trauma surgery to psychological factors such as depression and anxiety. Their findings demonstrated significant correlations between postoperative pain scores, disability indices, and psychological distress, highlighting that the consequences of trauma extend beyond the physical domain into the psychological and emotional spheres. This insight is critical, as the persistence of pain and functional limitations following surgery is often accompanied by mental health challenges that exacerbate recovery difficulties.

Recent global estimates suggest that traumatic injuries account for over 10% of the global disease burden, with approximately 50 million cases of orthopedic trauma reported annually, many leading to chronic pain and long-term disability[2]. Despite major advances in surgical and rehabilitative techniques, up to 30%-40% of trauma survivors continue to experience persistent pain, fatigue, and psychological distress months or even years after injury. Current rehabilitation programs often focus primarily on biomechanical restoration, overlooking psychological and social factors that critically shape recovery outcomes. This gap highlights the need for more comprehensive, biopsychosocial oriented frameworks that address the interplay between physical, emotional, and contextual determinants of recovery.

From a clinical perspective, this study calls attention to the need for a biopsychosocial framework in the management of orthopedic trauma. Chronic pain and disability are not solely biomedical outcomes but also deeply interwoven with patients’ psychological resilience, sleep quality, coping strategies, and prior trauma exposure. As Magruder et al[3] emphasized, trauma itself is a significant public health issue, and its sequelae are multidimensional, requiring integration of mental health care in rehabilitation planning. Similarly, epidemiological studies underscore the immense burden of traumatic injuries, not only in terms of direct healthcare costs but also through their long-term psychosocial and economic consequences[2]. Thus, Yang et al’s study[1] reinforces the urgent need for multidisciplinary strategies that simultaneously address the body and the mind, ensuring more holistic and sustainable recovery. What distinguishes Yang et al’s study[1] from prior research is its comprehensive integration of psychological variables - specifically depression and anxiety - into postoperative outcome assessment, offering one of the first large-scale analyses in orthopedic trauma that quantifies these associations through validated clinical measures. This provides novel evidence that psychological distress is not merely a secondary reaction to pain, but an independent predictor of disability and functional recovery.

THE IMPORTANCE OF THE PSYCHOLOGICAL DIMENSION IN POST-TRAUMATIC RECOVERY

Chronic pain following trauma is not merely the result of tissue or nerve injury; rather, it is increasingly understood as a complex interplay of physical, psychological, and social determinants. For instance, Landmark et al[4] demonstrated in a cohort of over 4000 chronic pain patients that psychological distress, catastrophizing, insomnia, and fatigue were among the strongest predictors of disability. Notably, insomnia and pain severity were identified as the most potent determinants of functional impairment, underscoring that psychological and behavioral factors can outweigh biomedical predictors in shaping recovery trajectories[4]. These findings reinforce that recovery cannot be effectively addressed without incorporating psychological screening and targeted interventions[1].

The fear-avoidance model of pain, extensively reviewed by Rogers and Farris[5], further elucidates how anxiety, fear of movement, and maladaptive cognitions can perpetuate pain and disability. Patients who develop heightened fear responses to pain may reduce activity levels, leading to deconditioning, social withdrawal, and exacerbation of psychological distress, a vicious cycle highly relevant to post-trauma populations. In this regard, these associations provide strong clinical justification for routine psychosocial assessments during orthopedic rehabilitation[1].

Beyond cognition, coping strategies also shape outcomes. Research by Loose et al[6] on individuals with chronic orofacial pain revealed that maladaptive coping mechanisms, such as avoidance or reliance on passive strategies, were strongly linked to poorer pain-related outcomes. Conversely, adaptive coping was protective, suggesting that structured psychological interventions, such as cognitive-behavioral therapy or resilience training, could buffer against chronic disability in orthopedic patients. This aligns with Dong et al[7] who applied a knowledge, attitude, belief, and practice model in trauma-related pain management, demonstrating that structured psychoeducation enhanced pain coping and reduced adverse outcomes.

Furthermore, evidence from Kaleycheva et al[8] in fibromyalgia patients shows that lifetime exposure to stressors significantly increases vulnerability to chronic pain syndromes. This finding highlights the broader psychosocial context in which orthopedic trauma occurs. Patients with histories of psychological stress or adverse life events may be particularly predisposed to developing persistent pain and disability after surgery. Integrating this knowledge into post-trauma care would enable clinicians to more effectively identify at-risk populations and tailor interventions accordingly.

Taken together, the findings of Yang et al[1] resonate with a large and growing body of literature affirming that psychological health is not a peripheral concern but a core determinant of recovery in orthopedic trauma. Neglecting these dimensions risks incomplete rehabilitation, lower patient satisfaction, and poorer long-term outcomes. By embedding mental health support within orthopedic care pathways, clinicians can address both the physical and emotional scars of trauma, ultimately promoting a more holistic and durable recovery.

SLEEP AND FATIGUE IN POST-TRAUMA RECOVERY

Sleep disturbances are among the most pervasive and debilitating consequences faced by patients recovering from orthopedic trauma. While Yang et al[1] primarily focused on the correlations between chronic pain, disability, and psychological factors such as anxiety and depression, the role of sleep dysfunction emerges as an equally critical mediator that bridges the physical and psychological domains of recovery. Insomnia and disrupted sleep cycles exacerbate pain and psychological distress, creating a self-reinforcing barrier to rehabilitation.

For example, Kaleycheva et al[8] conducted a population-level analysis and found that individuals with chronic pain and comorbid psychiatric conditions had significantly higher rates of insomnia and poor sleep quality compared to healthy controls. Importantly, sleep problems were not only outcomes but also predictors of worsening pain and disability over time. Similarly, Nap-van der Vlist et al[9] found that severe sleep disturbances predict higher distress and poorer treatment outcomes. Their findings underscore that rehabilitation programs which fail to address sleep problems may inadvertently compromise functional outcomes.

Sleep-related impairments also carry neurobiological correlates. Chen et al[10] demonstrated that disruption of the exchange proteins directly activated by cyclic adenosine monophosphate/phosphorylated caveolin-1 pathway following surgical incision contributed to chronic postsurgical pain through endothelial barrier dysfunction. Although not explicitly a sleep study, their findings suggest that systemic disruptions after surgery - such as those involving inflammatory pathways - may interact with sleep deprivation to intensify pain. Neuroimaging evidence further supports these interactions. Ma et al[11] identified grey matter abnormalities in osteoarthritis patients, linking structural brain changes to both pain perception and psychological burden. Sleep deprivation has been shown in other populations to exacerbate such neural vulnerabilities, raising concern that poor sleep-in orthopedic trauma patients could accelerate maladaptive neuroplasticity.

Fatigue is another dimension closely tied to poor sleep and psychological distress in this population. The fear-avoidance model described by Rogers and Farris[5] posits that catastrophizing and avoidance behaviors not only perpetuate pain but also lead to increased fatigue through reduced activity and disrupted sleep cycles. Indeed, fatigue was identified by Landmark et al[4] as one of the strongest predictors of disability in chronic pain patients, reinforcing its clinical significance.

From a practical standpoint, these findings suggest the need to integrate sleep assessments and interventions into post-trauma care. Non-pharmacological strategies such as cognitive-behavioral therapy for insomnia, chronotherapy, and relaxation techniques have demonstrated efficacy in improving both sleep quality and mood in various clinical contexts. In orthopedic populations, perioperative protocols that include sleep hygiene education, structured rest schedules, and monitoring of circadian alignment could substantially improve recovery outcomes. Additionally, Qiu et al[12] demonstrated the benefits of erector spinae plane blocks in improving perioperative analgesia and reducing opioid requirements. In line with current clinical recommendations, the European Pain Federation and the American Academy of Sleep Medicine advocate for integrating sleep hygiene education and cognitive-behavioral therapy for insomnia into chronic pain rehabilitation protocols, as these approaches have shown consistent benefits in improving both sleep and functional recovery. Such interventions may indirectly benefit sleep quality by decreasing nocturnal pain, which is one of the most common barriers to restorative sleep[12].

In summary, sleep and fatigue function as key mediators between pain, psychological distress, and disability. Ignoring these domains risks perpetuating a cycle of suffering where pain leads to insomnia, insomnia exacerbates depression and anxiety, and psychological distress further magnifies disability. By acknowledging and addressing sleep dysfunction as a central pillar of post-trauma recovery, clinicians can promote more comprehensive and effective rehabilitation strategies that align with Yang et al[1] call for the integration of psychological dimensions into orthopedic care.

NEUROBIOLOGICAL AND CENTRAL MECHANISMS OF PAIN

Yang et al[1] highlighted the association between chronic pain, disability, and psychological factors, but it is also essential to consider the neurobiological mechanisms underlying these outcomes. Trauma-related pain is not only the result of peripheral injury; it reflects a combination of inflammation, central sensitization, and maladaptive neuroplasticity that interact with psychological distress. Peripheral inflammation contributes to pain persistence. Chen et al[10] demonstrated that activation of the exchange proteins directly activated by cyclic adenosine monophosphate/phosphorylated caveolin-1 pathway following surgery disrupted endothelial function and promoted chronic postsurgical pain. Similarly, Dvorak et al[13] reported that fracture-related infection and sepsis can intensify systemic inflammatory responses, further sensitizing central pain pathways. Elevated inflammatory cytokines such as interleukin-6 and tumor necrosis factor-α have also been associated with both heightened nociception and depressive symptoms, suggesting that immune dysregulation may serve as a shared pathway for physical and emotional suffering. Such processes may be intensified by stress, poor sleep, and anxiety. Central sensitization is another key mechanism. Kaleycheva et al[8] reported that exposure to stressors increases vulnerability to sensitization, predisposing individuals to chronic pain. Similarly, neuroplastic changes in the brain have been observed in osteoarthritis patients, where alterations in grey matter have been linked to pain and psychological burden[11]. These biological processes are reinforced by psychological factors. As Rogers and Farris[5] noted, fear and avoidance behaviors sustain central sensitization and disability. Thus, biological and psychological mechanisms are interdependent. Overall, Yang et al’s findings[1] fit within this biopsychosocial framework. Addressing both the neural underpinnings of pain and the psychological patterns that maintain them is essential for more comprehensive and durable recovery after orthopedic trauma.

CENTRAL PLASTICITY AND NEURAL REMODELING

Beyond peripheral mechanisms, central nervous system plasticity plays a pivotal role in sustaining pain states after trauma. Lee et al[14] provided experimental evidence that spinal cord injury-induced hyperreflexia results from maladaptive remodeling of cutaneous afferents, demonstrating how central plasticity can heighten nociceptive sensitivity long after tissue repair. This phenomenon of central sensitization is well-recognized in chronic pain syndromes and has strong implications for orthopedic trauma patients. Neuroimaging studies further support this, with Ma et al[11] demonstrating that osteoarthritis patients exhibit significant grey matter abnormalities in brain regions associated with pain modulation and emotional regulation. Such neural changes may partly explain why chronic pain is often accompanied by psychological disturbances. These results suggest that post-traumatic pain should be conceptualized not only as a musculoskeletal issue but also as a disorder of the central nervous system, highlighting the importance of early interventions such as multimodal analgesia and psychological therapies.

FEAR, AVOIDANCE, AND NEUROCOGNITIVE CIRCUITS

The fear-avoidance model of pain, as elaborated by Rogers and Farris[5], offers a psychosocial framework that integrates well with these neurobiological insights. Catastrophizing and hypervigilance toward pain stimuli may activate limbic circuits and stress responses, reinforcing central sensitization. Neurocognitive mechanisms, therefore, become a bridge between psychological risk factors and biological changes, perpetuating a vicious cycle of pain, disability, and emotional distress. This highlights the need for early interventions targeting maladaptive cognitions, as failure to address these psychological triggers may lock patients into long-term neuroplastic changes that are difficult to reverse.

IMPLICATIONS FOR POST-TRAUMA CARE

Taken together, the evidence suggests that the persistence of pain after orthopedic trauma reflects not merely a local phenomenon but a systemic and central process influenced by inflammatory, neural, and psychological pathways. Addressing these neurobiological contributors requires a multimodal approach. Pharmacological strategies targeting inflammatory cascades, such as anti-cytokine therapies, may complement psychological interventions like cognitive-behavioral therapy, which address maladaptive cognitions. Moreover, regional anesthesia techniques such as the erector spinae plane block, reviewed by Qiu et al[12], provide a valuable method for modulating perioperative nociceptive input, thereby reducing the risk of central sensitization.

Yang et al’s findings[1] fit within this framework, as the observed correlations between depression, anxiety, and disability likely reflect the downstream effects of both neuroinflammatory processes and maladaptive central plasticity. Recognizing these connections is vital, as it expands the focus of rehabilitation from symptom control to addressing the underlying biological and psychological interface.

MULTIDISCIPLINARY INTEGRATION

A multidisciplinary team approach is essential to manage the interplay of chronic pain, disability, and psychological distress. For instance, physical therapists can collaborate with nurses to implement activity pacing and graded exercise programs that counteract fear-avoidant behaviors described[5]. Psychologists can deliver evidence-based interventions such as cognitive-behavioral therapy or acceptance and commitment therapy, which have demonstrated effectiveness in reducing catastrophizing and enhancing coping[6]. Physicians and anesthesiologists can integrate pharmacological and interventional strategies, such as regional blocks or neuromodulation, to reduce nociceptive input and thereby support psychological interventions[12,15]. Nurses, at the center of this team, ensure continuity of care by coordinating these services and tailoring them to patients’ individual psychosocial needs. The role of psychoeducation is particularly important, as patients who understand the biopsychosocial nature of pain are more likely to engage in multidisciplinary strategies. In real clinical settings, effective implementation of multidisciplinary integration requires clear communication channels between orthopedic, nursing, and mental health teams. Barriers such as limited time, insufficient staff training, and lack of psychological service accessibility can hinder this process. Developing structured referral pathways, interprofessional education programs, and routine psychosocial screening protocols may help overcome these obstacles and promote consistent biopsychosocial care delivery. As Magruder et al[2] noted, trauma must be treated as a public health issue, demanding approaches that extend beyond surgery to include social and psychological care.

THE VALUE OF HOLISTIC MODELS

Research in chronic pain and fibromyalgia supports integrating psychosocial care into routine orthopedic practice. Kaleycheva et al[8] highlighted how lifetime exposure to stressors increased vulnerability to chronic pain syndromes, pointing to the importance of early identification and holistic interventions. Similarly, Landmark et al[4] showed that insomnia, fatigue, and catastrophizing - not just pain severity - were the strongest predictors of disability, reinforcing the need for interventions that target psychological as well as physical outcomes. These insights align with the narrative nursing framework, which emphasizes individualized, person-centered care as a means of addressing both emotional and physical trauma recovery.

The integration of psychological support into orthopedic care also reduces the stigma patients may experience when their suffering is not validated through biomedical markers alone. Narrative nursing legitimizes patients’ experiences, fostering empowerment and reducing isolation. In turn, this can improve compliance with rehabilitation protocols, medication adherence, and engagement in physical therapy, leading to more favorable long-term outcomes.

INTEGRATED CLINICAL IMPLICATIONS AND BIOPSYCHOSOCIAL MODEL

In practice, incorporating psychological assessment tools into orthopedic nursing protocols is a feasible first step. Instruments such as depression and anxiety scales, alongside sleep and fatigue assessments, can guide tailored interventions, with clear referral pathways to mental health services for at-risk patients. Interdisciplinary training programs would further ensure that nurses and allied health professionals are prepared to recognize and address psychosocial risk factors early in the recovery process. These practical steps reflect the broader shift from a purely biomedical framework toward a biopsychosocial model of care. Chronic pain and disability are not determined solely by surgical repair or tissue damage but emerge from an interplay of biological, psychological, and social determinants[1]. Biological advances emphasize systemic processes such as inflammation and central sensitization[10,11,13], while psychological distress - depression, anxiety, and maladaptive coping - emerges as an equally powerful determinant of outcome[4,5]. Social challenges, including economic burden and role disruption, further complicate recovery[2,3]. A routine biopsychosocial pathway - combining psychological screening, sleep-focused interventions, coping-based psychoeducation, and multimodal analgesia within a nursing-led multidisciplinary team - offers the most realistic route to reduce chronic pain risk and restore long-term quality of life.

BIOLOGICAL FOUNDATIONS

On the biological side, advances in trauma and neuroinflammation research underscore the role of systemic processes in pain persistence. Studies such as those by Chen et al[10] and Dvorak et al[13] have shown that inflammatory cascades triggered by surgical injury or fracture-related infection can prolong nociception and sensitize central pain pathways. Evidence from neuroimaging studies, including Ma et al[11], demonstrates structural and functional brain alterations in pain populations, confirming that chronic pain is a disorder not only of the body but also of the brain. These insights necessitate interventions that go beyond surgical repair, incorporating multimodal pain control and anti-inflammatory strategies to mitigate neuroplastic changes that perpetuate suffering.

PSYCHOLOGICAL DETERMINANTS

Psychological distress - depression, anxiety, catastrophizing, and maladaptive coping - emerges as an equally powerful determinant of outcomes. Yang et al[1] identified significant correlations between psychological distress and clinical outcomes, findings echoed in larger population studies. For example, Landmark et al[4] demonstrated that insomnia and catastrophizing were stronger predictors of disability than pain intensity itself. Similarly, Rogers and Farris[5] highlighted how fear and avoidance behaviors perpetuate disability. Collectively, these findings underscore that psychological assessment should be an indispensable component of orthopedic trauma rehabilitation, not an optional adjunct.

SOCIAL AND CONTEXTUAL INFLUENCES

Beyond biological and psychological dimensions, social determinants also play a role in recovery. Trauma survivors may face economic hardship, employment loss, and reduced social participation, all of which can complicate rehabilitation outcomes[2,3].

CONCLUSION

The study by Yang et al[1] strengthens the evidence that psychological factors are central determinants of pain and disability after orthopedic trauma. A routine biopsychosocial pathway - combining psychological screening, sleep-focused interventions, coping-based psychoeducation, and multimodal analgesia within a nursing-led multidisciplinary team - offers the most realistic route to reduce chronic pain risk and restore quality of life.